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Healthcare Cost Hardship Plan (HCHP)

To provide financial assistance to Dartmouth College employees enrolled in the Cigna Open Access Plan 1 (OAP1) or Cigna Open Access Plan 2 (OAP2) whose out of pocket expenses (not including premium contributions) exceed 7% of their household income. Out of pocket expenses are defined as: Copayments, Deductibles, Coinsurance.

By design, this program will most benefit employees whose household is experiencing an unusual medical claim year and whose household income is in the lower ranges.

This program does not apply to the $2500 high deductible health plan.

Eligibility for Reimbursement

Maximum Annual Reimbursement

Approval and Payment

How to Apply

Documentation Required

Whom to Contact

ELIGIBILITY FOR REIMBURSEMENT

  • Dartmouth College employees with a minimum of 1 year of continued service.
  • Dartmouth College employees currently enrolled in the Cigna OAP1 or Cigna OAP2 plans.
    • Dartmouth College will verify participation in Cigna plan following receipt of application.
  • Reimbursement is for expenses exceeding 7% of household income.
    • Household income is determined by the Adjusted Gross Income (AGI) from previous year tax return (Line 37 of 2010 IRS Form 1040).
  • Reimbursement includes all out-of-pocket costs for services covered by the OAP1 and OAP2 plan within a single year.
  • Flexible Spending Account (FSA) funds must be exhausted before requesting reimbursement. This will be verified by Crosby Benefits.
    • FSA funds can be used for eligible expenses not associated with this application.
    • Your elected contribution and the College contribution of $250* toward the FSA must be exhausted.
      • *Non-exempt staff and those employees earning $60,000 or less are automatically given $250 in a Health Care Flexible Spending account.  If you are part-time or your hire date is after January 1st, the amount will be prorated.
      • In the case where spouses are both employees at Dartmouth College and each receives the College contribution to the FSA, the total amount of both these FSAs must be exhausted before requesting reimbursement
  • Employees who meet all other eligibility requirements and who also receive their medical benefits through COBRA are eligible.

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MAXIMUM ANNUAL REIMBURSEMENT

All out-of-pocket costs greater than 7% of household income are eligible for reimbursement.  Out-of-pocket costs may include co-payments, coinsurance and deductibles.

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APPROVAL AND PAYMENT

  • Reimbursement will be processed through a third party administrator, Crosby Benefits, only at designated times: June, September, December and March.
    • Deadlines to submit applications and documentation in order to receive reimbursement will be one month prior to the designated times above (ex. deadline to submit is May 1st for June 1st reimbursement).
  • A completed application form, with supporting documentation, must be submitted to Crosby Benefits.
    • Failure to provide all necessary information on or attached to the application form, or to respond to requests for additional information, will result in a denial of the request.
  • Crosby Benefits will send notification of approval/denial and request/return documentation as needed.
  • If an employee is approved for reimbursement and incurs expenses after approval, and within the same tax year, the employee can submit subsequent documentation to Crosby Benefits with a new application cover sheet.
  • The reimbursement will be considered non-taxable income.

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HOW TO APPLY

Complete the Healthcare Cost Hardship Plan Application and return it to Crosby Benefits with the Required Documentation.

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DOCUMENTATION REQUIRED

  • Healthcare Cost Hardship Plan Application
  • Previous year's tax return, including Adjusted Gross Income (AGI) (Line 37 of 2010 IRS Form 1040)
  • Supporting medical documentation (ex. bills and receipts).  These documents must itemize expenses.

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WHOM TO CONTACT

Crosby Benefit Systems, Inc.

Phone: 617-928-0700

Fax: 617-928-0001

E-mail: servicecenter@crosbybenefits.com

Mail: 27 Christina Street, Newton, MA 02461

Website: http://www.crosbybenefits.com

 

Human Resources - Benefits Office

E-mail: Human.Resources.Benefits@dartmouth.edu

Phone: 603-646-3588

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Last Updated: 8/20/14